The present study investigates patient perceptions of the quality of discharge instruction by assessing inpatients' ratings of care and service in the United States over the past 5 years (1997-2001) (n = 4,901,178). As expected, patients' ratings of "instructions given about how to care for yourself at home" showed a strong, consistent positive relationship with overall patient satisfaction from 1997 through 2001. Nevertheless, patient satisfaction with discharge instructions decreased significantly each year (p < 0.001). Patients gave lower ratings to the quality of discharge instruction than to the overall quality of their hospital stay which indicates a failure to match the quality delivered among other services within the hospital. Patient assessments of discharge instruction quality varied systematically among conditions. Patients with musculoskeletal diseases and disorders (MDC-8) rated discharge instruction considerably lower than all other patient groups. Patients' age, sex, self-described health status and length of stay did not predict patients' evaluations of discharge instructions. U.S. hospitals may not be meeting existing AMA and JCAHO standards for patient education and discharge.